The impact of traditional birth attendant training on delivery complications in Ghana.

OBJECTIVES: In their efforts to reduce maternal and neonatal morbidity and mortality, many national and international agencies make considerable investments in training traditional birth attendants (TBAs). The value of TBA training is controversial, and plausible arguments are made both for and against. Numerous process evaluations are reported in the literature and the results are mixed, though generally positive. Outcome evaluations, however, are scarce. This article describes an outcome evaluation of TBA training conducted in two districts of Brong-Ahafo Region, Ghana, during 1996. DESIGN AND METHODS: Data from a random sample survey of 1961 clients of TBAs were subjected to logistic regression modelling to determine the effect of training on maternal outcomes, controlling for other independent variables. RESULTS: Of eight outcomes modelled, three were associated with training and five were not. Three additional outcomes were not modelled, primarily due to low prevalence. CONCLUSIONS: Despite some inherent design limitations, this study found that the evidence for a beneficial impact of TBA training was not compelling. Training sponsors should consider alternative health investments and, where TBA training remains the intervention of choice, be realistic about expectations of impact.

Anthelminthic treatment and haemoglobin concentrations during pregnancy.

A longitudinal study was conducted in Sierra Leone to measure the impact of a single dose anthelminthic (400 mg albendazole) and daily iron-folate supplements (36 g iron and 5 mg folate) on haemoglobin (HG) concentration during pregnancy. After controlling for baseline Hb concentration and season, anthelmintic treatment reduced the decline in haemoglobin concentration between the first and third trimesters by 6.6 g/L (p=0.0034) relative to the control. The corresponding value for iron-folate supplements was 13.7 g/L(p<0.0001) [corrected]. These findings indicate that anthelminthic treatment should be included in strategies to control maternal anaemia in Sierra Leone.

Implementing the integration of component services for reproductive health.

In the wake of the 1994 International Conference on Population and Development in Cairo, considerable activity has occurred both in national policymaking for reproductive health and in research on the implementation of the Cairo Program of Action. This report considers how effectively a key component of the Cairo agenda--integration of the management of sexually transmitted infections, including human immunodeficiency virus, with maternal and child health-family planning services--has been implemented. Quantitative and qualitative data are used to illuminate the difficulties faced by implementers of reproductive health programs in Ghana, Kenya, South Africa, and Zambia. In these countries, clear evidence is found of a critical need to reexamine the continuing focus on family planning services and the nature of the processes by which managers implement reproductive health policies. Implications of findings for policy and program direction are discussed.

National immunisation days for polio eradication in Uganda: did immunisation cards increase coverage?

OBJECTIVE: To analyse the effect of cards and of vitamin A supplementation on coverage for National Immunisation Days (NIDs). DESIGN: A retrospective ecological study. SETTING: A countrywide NIDs coverage before and after introduction of the NIDs cards and vitamin A supplementation in all districts of Uganda. METHODS: NIDs for polio eradication commenced in Uganda in 1996. Two rounds, one month apart are implemented yearly. During the second round of 1998 NIDs, cards were introduced nationally and vitamin supplementation was introduced in 24 of the 45 districts. We compared NIDs coverage before and after NIDs cards and NIDs coverage in districts that implemented vitamin A to those that did not. RESULTS: After introduction of NIDs cards, the national coverage rose from 97.7% to 106.9%, an increase of 9.2%. In those districts that implemented vitamin A supplementation, the NIDs coverage rose from 100.1% to 111.5%, an increase of 10.4%. In those districts that did not implement vitamin A, the NIDs coverage rose by 6.7% from 94.5% to 102.2%. Before the introduction of cards and vitamin A in 1996 and 1997, the NIDs coverage was between 92-96%. CONCLUSION: NIDs cards and vitamin A supplementation could have increased the NIDs national coverage.

PIP: A retrospective ecological study was carried out to analyze the effect of cards and vitamin A supplementation on coverage for National Immunization Days (NIDs) in Uganda. Commenced in 1996, NIDs for polio eradication in Uganda are implemented twice a year, one month apart. During the second round of 1998 NIDs, cards were introduced nationally and vitamin A supplementation was introduced in 24 of the 45 districts. NIDs coverage before and after the introduction of cards and NIDs coverage in districts implementing and those not implementing vitamin A supplementation were compared. After introduction of NID cards, the national coverage increased by 9.2% (from 97.7% to 106.9%). In those districts that implemented vitamin A supplementation, a 10.4% rise in NIDs coverage was noted (from 100.1% to 111.5%). NIDs coverage in those districts that did not implement vitamin A supplementation rose from 94.5% to 102.2%, an improvement of 6.7%. Based on these findings, it was concluded that NIDs cards and vitamin A supplementation could have increased the NIDs national coverage.

Aetiology, outcome, and risk factors for mortality among adults with acute pneumonia in Kenya.

BACKGROUND: Despite a substantial disease burden, there is little descriptive epidemiology of acute pneumonia in sub-Saharan Africa. We did this study to define the aetiology of acute pneumonia, to estimate mortality at convalescence, and to analyse mortality risk-factors. METHODS: We studied 281 Kenyan adults who presented to two public hospitals (one urban and one rural) with acute radiologically confirmed pneumonia during 1994-96. We did blood and lung-aspirate cultures, mycobacterial cultures, serotype-specific pneumococcal antigen detection, and serology for viral and atypical agents. FINDINGS: Aetiology was defined in 182 (65%) patients. Streptococcus pneumoniae was the most common causative agent, being found in 129 (46%) cases; Mycobacterium tuberculosis was found in 26 (9%). Of 255 patients followed up for at least 3 weeks, 25 (10%) died at a median age of 33 years. In multivariate analyses, risk or protective factors for mortality were age (odds ratio 1.51 per decade [95% CI 1.04-2.19]), unemployment (4.42 [1.21-16.1]), visiting a traditional healer (5.26 [1.67-16.5]), visiting a pharmacy (0.30 [0.10-0.91]), heart rate (1.64 per 10 beats [1.24-2.16]), and herpes labialis (15.4 [2.22-107]). HIV-1 seropositivity, found in 52%, was not associated with mortality. Death or failure to recover after 3 weeks was more common in patients with pneumococci of intermediate resistance to benzylpenicillin, which comprised 28% of pneumococcal isolates, than in those infected with susceptible pneumococci (5.60 [1.33-23.6]). INTERPRETATION: We suggest that tuberculosis is a sufficiently common cause of acute pneumonia in Kenyan adults to justify routine sputum culture, and that treatment with benzylpenicillin remains appropriate for clinical failure due to M. tuberculosis, intermediate-resistant pneumococci, and other bacterial pathogens. However, interventions restricted to hospital management will fail to decrease mortality associated with socioeconomic, educational, and behavioural factors.

Experiences of breastfeeding and vulnerability among a group of HIV-positive women in Durban, South Africa.

While international guidelines are currently being drawn up about HIV and infant feeding practices, and national and regional guidelines are under discussion in South Africa, there have been remarkably few studies that have sought to elicit HIV-positive mothers' experiences of breastfeeding and of paediatric infection. There is an urgent need to document this 'grass roots' knowledge in different sites, and for this data to be used to inform policy development, and for advocacy and counselling purposes. This qualitative investigation reports on the experiences and decisions taken around breastfeeding by a peer support group of 13 HIV-positive mothers meeting at King Edward VIII Hospital, Durban. In this study, the particular focus of information-giving and decision-making as to breast or formula feed is concerned with the impact on individual HIV-positive women and their babies. The most significant finding is that at no stage during their pregnancy were any of these mothers given information about the risks of HIV transmission through breastmilk. The study data were elicited in an in-depth group discussion, and individual women were invited to re-enact their stories in a follow-up discussion for clarification purposes. The women also discussed how they dealt with problems surrounding confidentiality in cases where few have been able to disclose their status to the extended family. There have been renewed calls for further investment in counsellors, with an enhanced role for community activists as peer educators. While there are severe resource constraints and low morale among many overworked nurses, one of the general problems in hospital settings remains the vertical health paradigm. This does not accommodate women's experiences, preferences, social networks and lay knowledge, and inhibits many women from becoming full participants in decisions affecting their own and their family's health.

Treatment in Kenyan rural health facilities: projected drug costs using the WHO-UNICEF integrated management of childhood illness (IMCI) guidelines.

Guidelines for the integrated management of childhood illness (IMCI) in peripheral health facilities have been developed by WHO and UNICEF to improve the recognition and treatment of common causes of childhood death. To evaluate the impact of the guidelines on treatment costs, we compared the cost of drugs actually prescribed to a sample of 747 sick children aged 2-59 months in rural health facilities in western Kenya with the cost of drugs had the children been managed using the IMCI guidelines. The average cost of drugs actually prescribed per child was US$ 0.44 (1996 US$). Antibiotics were the most costly component, with phenoxymethylpenicillin syrup accounting for 59% of the cost of all the drugs prescribed. Of the 295 prescriptions for phenoxymethylpenicillin syrup, 223 (76%) were for treatment of colds or cough. The cost of drugs that would have been prescribed had the same children been managed with the IMCI guidelines ranged from US$ 0.16 per patient (based on a formulary of larger-dose tablets and a home remedy for cough) to US$ 0.39 per patient (based on a formulary of syrups or paediatric-dose tablets and a commercial cough preparation). Treatment of coughs and colds with antibiotics is not recommended in the Kenyan or in the IMCI guidelines. Compliance with existing treatment guidelines for the management of acute respiratory infections would have halved the cost of the drugs prescribed. The estimated cost of the drugs needed to treat children using the IMCI guidelines was less than the cost of the drugs actually prescribed, but varied considerably depending on the dosage forms and whether a commercial cough preparation was used.

PIP: This study evaluated the impact of the integrated management guidelines of childhood illness (IMCI) developed by the WHO and UN Children's Fund on the treatment cost in Kenya. To determine the impact of the guidelines, a comparison was made of the cost of drugs actually prescribed to 747 sick children aged 2-59 months in rural facilities with the treatment cost had the children been managed following the IMCI guidelines. The study found that the estimated cost of drugs required to treat children following the IMCI guidelines was lower than the cost of the drugs actually prescribed in ill children. The average cost of drugs actually prescribed for every sick child was US$0.44. Antibiotics were the most expensive component, with phenoxymethylpenicillin syrup responsible for 59% of the total cost of prescribed drugs. The cost of medications that would have been prescribed had the children been treated using the guidelines ranges from US$0.16 to US$0.39 per patient. Managing cough and colds with antibiotics is not recommended in the IMCI guidelines, thus, compliance to guidelines would have reduced the treatment cost to one half the cost of drugs actually prescribed.

Integrating reproductive health: myth and ideology.

Since 1994, integrating human immunodeficiency virus/sexually transmitted disease (HIV/STD) services with primary health care, as part of reproductive health, has been advocated to address two major public health problems: to control the spread of HIV; and to improve women's reproductive health. However, integration is unlikely to succeed because primary health care and the political context within which this approach is taking place are unsuited to the task. In this paper, a historical comparison is made between the health systems of Ghana, Kenya and Zambia and that of South Africa, to examine progress on integration of HIV/STD services since 1994. Our findings indicate that primary health care in Ghana, Kenya and Zambia has been used mainly by women and children and that integration has meant adding new activities to these services. For the vertical programmes which support these services, integration implies enhanced collaboration rather than merged responsibility. This compromise between comprehensive rhetoric and selective reality has resulted in little change to existing structures and processes; problems with integration have been exacerbated by the activities of external donors. By comparison, in South Africa integration has been achieved through political commitment to primary health care rather than expanding vertical programmes (top-down management systems). The rhetoric of integration has been widely used in reproductive health despite lack of evidence for its feasibility, as a result of the convergence of four agendas: improving family planning quality; the need to improve women's health; the rapid spread of HIV; and conceptual shifts in primary health care. International reproductive health actors, however, have taken little account of political, financial and managerial constraints to implementation in low-income countries.

PIP: This paper provides a historical comparison between the health systems in Ghana, Kenya and Zambia and South Africa, to examine progress on integration of HIV/STD services since 1994. Findings gathered from the study conducted during 1997-98 revealed that the primary health care in Ghana, Kenya and Zambia has been used mainly by women and children and that integration has meant adding new activities to these services. For the vertical program which support these services, integration implies enhanced collaboration rather than merged responsibility. This compromise between comprehensive rhetoric and selective reality has resulted in little change to existing structures and processes; problems with integration have been exacerbated by the activities of external donors. By comparison, in South Africa integration has been achieved through political commitment to primary health care rather than expanding vertical programs (top-down management systems).

Caring for people with HIV in Zambia: are traditional healers and formal health workers willing to work together?

This study of traditional healers and formal health workers determined their knowledge and practices in the field of HIV/AIDS and examined their training needs and attitudes to collaboration, in preparation for planning joint training workshops. Several misconceptions concerning symptoms and transmission of HIV disease were found in both groups, particularly among traditional healers. Twenty healers (51%) and four formal health workers (15%) claimed a cure existed for AIDS. The majority of traditional healers interviewed expressed difficulties discussing a diagnosis of HIV directly with patients, mainly due to fear of the patient becoming depressed and suicidal. Most interviewees wanted more training--the majority of traditional healers in recognizing symptoms of HIV/AIDS and their treatment, and the majority of formal health workers in HIV counselling. Most were interested in supplying condoms. Almost all healers and half of the formal health workers were keen to collaborate in training and patient care. The study indicates that there is willingness amongst Zambian traditional healers and formal health workers to collaborate in training and patient care in the field of HIV/AIDS. As well as covering symptoms, transmission and prevention of HIV/AIDS, training should aim to increase ability to openly discuss HIV with patients, which many traditional healers and some formal health workers find difficult. Involving traditional healers in supplying condoms may improve acceptability and availability, particularly in rural areas.

PIP: A knowledge questionnaire and a semistructured interview was conducted with 39 traditional leaders (22 males and 17 females) and 27 formal health workers (4 men and 23 women) to determine their knowledge and practices in the field of HIV/AIDS; additionally, their training needs and attitudes to collaboration, in preparation for planning joint training workshops, were examined. Areas explored included symptoms and transmission of HIV/AIDS, treatment, personal risk, condom use and distribution, traditional practices, education and prevention, HIV counseling and testing and collaboration between healers and health workers. Results showed that misconceptions and gaps concerning transmission and symptoms existed in both groups, particularly among the traditional healers. 20 traditional healers (51%) and 4 formal health workers (15%) claimed that a cure for AIDS existed. Most health workers and traditional healers found discussing a diagnosis of HIV directly with patients difficult because of fears that it might make them depressed or suicidal. However, many healers were keen to participate in condom distribution. There was more support for collaboration among traditional healers than among formal health workers; almost all formal health workers but only 8 traditional healers knew of voluntary HIV counseling. Both traditional healers and formal health workers have significant and complementary roles in the field of HIV/AIDS in Zambia, but there is much debate concerning the relationship between them.

Intracluster correlation of STD prevalence in a community intervention trial in Kenya.

This study is a cluster-randomised, community intervention trial to measure the impact of female condom introduction on STD prevalence among Kenyan agricultural workers. The intracluster correlation coefficient of baseline STD prevalences at the 12 sites was 0.0011.

PIP: A cluster-randomized, community intervention trial to measure the impact of female condom introduction on sexually transmitted disease (STD) prevalence was conducted among Kenyan agricultural workers. The intracluster correlation coefficient (ICC) was used to measure the degree of homogeneity within clusters in comparison to total variability. The women in the sample population received condoms and were exposed to an STD prevention program through group meetings, video presentations, puppetry, and other folk media. They were also screened and tested for gonorrhea, chlamydia, and vaginal trichomoniasis. Tests were repeated after 6 and 12 months. The ICC of baseline STD prevalence at the 12 sites was 0.0011, and the proportion of women with STDs was higher at the control sites, which indicates a negligible clustering effect.

Foundations for effective strategies to control sexually transmitted infections: voices from rural Kenya.

Achieving maximal benefit from clinic-based, sexually transmitted infection (STI) control strategies requires that persons seek treatment at public clinics. Community-based, ethnographic research methods were used to examine patterns of health-seeking behavior for sexually transmitted infections in western Kenya. Illness narratives of sexually transmitted infections provided the basis for an analysis of sequential steps in health-seeking behavior, namely recognition, classification, overcoming stigma, identification of treatment options and selection of a course of therapy. A variety of terms were used to identify STI, including multiple terms referring to "women's disease". The stigma associated with STI, reflected in the terminology, was based on a set of beliefs on the causes, contagiousness and sequelae of STI, and resulted in delays in seeking treatment. Five commonly used treatment options were identified, with multiple sources of care often used concurrently. The desire for privacy, cost and belief in the efficacy of traditional medicines strongly influenced health-seeking behaviour. A belief that sexually transmitted infections must be transmitted in order to achieve cure was professed by several respondents and promoted by a traditional healer. Implications for STI control strategies are derived, including the development of educational messages and the design of clinics.

PIP: Data on health-seeking behavior were collected in Vihiga and Homa Bay Districts of western Kenya, as part of formative research for a sexually transmitted disease (STD) control and HIV/AIDS home care project with the main goal of securing information to guide project design and implementation. Community-based, ethnographic research methods were used from January 1995 to June 1996, including key informant interviews, focus group discussions, and in-depth interviews. Illness narratives of STDs provided the basis for an analysis of sequential steps in health-seeking behavior, namely recognizing, classifying, overcoming stigma, identifying treatment options, and selecting a course of therapy. A range of terms were used to identify STDs, including multiple terms referring to "women's disease." Stigma associated with STDs was based upon a set of beliefs of the causes, contagiousness, and sequelae of STDs, and resulted in treatment seeking delays. 5 commonly used treatment options were identified, with multiple sources of care often used concurrently. The desire for privacy, cost, and belief in the efficacy of traditional medicines strongly influenced health-seeking behavior. The belief that STDs must be transmitted in order to achieve cure was held by several respondents and promoted by a traditional healer. Implications for STD control strategies are considered, including the development of educational messages and clinic design.

A comparison of calcium, vitamin D, or both for nutritional rickets in Nigerian children.

BACKGROUND: Nutritional rickets remains prevalent in many tropical countries despite the fact that such countries have ample sunlight. Some postulate that a deficiency of dietary calcium, rather than vitamin D, is often responsible for rickets after infancy. METHODS: We enrolled 123 Nigerian children (median age, 46 months) with rickets in a randomized, double-blind, controlled trial of 24 weeks of treatment with vitamin D (600,000 U intramuscularly at enrollment and at 12 weeks), calcium (1000 mg daily), or a combination of vitamin D and calcium. We compared the calcium intake of the children at enrollment with that of control children without rickets who were matched for sex, age, and weight. We measured serum calcium and alkaline phosphatase and used a 10-point radiographic score to assess the response to treatment at 24 weeks. RESULTS: The daily dietary calcium intake was low in the children with rickets and the control children (median, 203 mg and 196 mg, respectively; P=0.64). Treatment produced a smaller increase in the mean (+/-SD) serum calcium concentration in the vitamin D group (from 7.8+/-0.8 mg per deciliter [2.0+/-0.2 mmol per liter] at base line to 8.3+/-0.7 mg per deciliter [2.1+/-0.2 mmol per liter] at 24 weeks) than in the calcium group (from 7.5+/-0.8 [1.9+/-0.2 mmol per liter] to 9.0+/-0.6 mg per deciliter [2.2+/-0.2 mmol per liter], P<0.001) or the combination-therapy group (from 7.7+/-1.0 [1.9+/-0.25 mmol per liter] to 9.1+/-0.6 mg per deciliter [2.3+/-0.2 mmol per liter], P<0.001). A greater proportion of children in the calcium and combination-therapy groups than in the vitamin D group reached the combined end point of a serum alkaline phosphatase concentration of 350 U per liter or less and radiographic evidence of nearly complete healing of rickets (61 percent, 58 percent, and 19 percent, respectively; P<0.001). CONCLUSIONS: Nigerian children with rickets have a low intake of calcium and have a better response to treatment with calcium alone or in combination with vitamin D than to treatment with vitamin D alone.

PIP: A randomized, double-blind, controlled trial was conducted to compare the efficacy of calcium, vitamin D, and a combination of both in the treatment of nutritional rickets among Nigerian children. Subjects included 123 Nigerian children with the deformity characteristics of rickets. For each child who was enrolled, a parent or guardian was asked to recruit a control child with the same sex, age, weight, and who had no clinical signs of rickets. Children with rickets were under treatment for 24 weeks with vitamin D (600,000 U intramuscularly at enrollment and at 12 weeks), calcium (1000 mg daily), or a combination of both. Then the serum calcium and alkaline phosphates were measured and a 10-point radiographic score was used to assess the response to the 24-week treatment. The results revealed a low dietary calcium intake in children with rickets and in control children. Children under vitamin D treatment appeared to have a small increase in the mean serum calcium concentration when compared to children under calcium treatment or a combination of both vitamin D and calcium. A greater proportion of children in the calcium and combination-therapy groups than in the vitamin D group reached the combined end point of a serum alkaline phosphates concentration of 350 U/liter or less and radiographic evidence of nearly complete healing of rickets. Overall, compliance ranged from 92% to 96% across the three groups. Since Nigerian children with rickets had low calcium intake, treatment should focus on dietary supplementation with calcium or a combination of calcium and vitamin D.

Effectiveness of primary level antenatal care in decreasing anemia at term in Tanzania.

BACKGROUND: In Tanzania the prevalence of anemia in pregnancy is high inspite of a high antenatal attendance and an established national policy of routine hematinic supplementation and malaria chemosuppression to all pregnant women, free of cost in all antenatal clinics. OBJECTIVES: To assess the effectiveness of reinforcing existing antenatal clinic routines for prevention and treatment of anemia in pregnancy, combined with individual and community health education. METHODS: A prospective controlled intervention study in two antenatal clinics at primary level. At booking (median 24 weeks), 1045 women were screened for anemia and followed-up to late pregnancy (gestational age > or =34 weeks). In addition to hematinic and malaria prophylaxis, extra interventions at the study clinic included retraining of staff, group and individual counselling of women and community health education in the area. RESULTS: There was a significant overall increase in median Hb from 10.1 g/dl at booking to 10.6 g/dl in late pregnancy, and prevalence of anemia (Hb < or =10.5 g/dl) was reduced from 60% at booking to 47%, at both clinics, with 57% reduction in the proportion with severe anemia (Hb <7.0 g/dl). Severely anemic women increased their median Hb by 3.2 g/dl during antenatal care. No additional effect was observed from an individual and community information program. CONCLUSION: Ensuring an adequate supply of drugs seems to be the most important activity to achieve safe hemoglobin levels in pregnant women, but even an active antenatal program has a limited effect when anemia is highly prevalent and booking is late.

PIP: This study assesses the effectiveness of primary level antenatal care in decreasing anemia among pregnant women in Tanzania. The sample included 1045 women screened for anemia and followed-up to late pregnancy. Extra interventions at the study clinic included retraining of staff, group and individual counseling of women, and community health education in the area. Results showed a significant overall increase in median Hb from 10.1 g/dl at booking to 10.6 g/dl in late pregnancy. Prevalence of anemia was reduced from 60% at booking to 47% at both clinics, with a 57% reduction in the proportion having severe anemia. Severely anemic women increased their median Hb by 3.2 g/dl during antenatal care. This study concludes that ensuring an adequate supply of drugs seems to be the most important activity to achieve safe hemoglobin levels in pregnant women, but even an active antenatal program has a limited effect when anemia is highly prevalent and booking is late.

[Memisa and home care for AIDS patients in Zambia]. / Memisa en de thuiszorg voor aidspatiënten in Zambia.

Health care in Zambia has since long been receiving support from non-governmental organizations (NGOs) like Memisa. Church organizations bear responsibility for a considerable part of the national health services. During the last 15 years, growing attention has been given to improvement of basic services in the villages and to recruitment and organization of groups in the community active in the field of health care. The combat against AIDS is a major focus. Many NGOs give health education on HIV and AIDS, are coaching HIV-positive individuals and are trying to organize support for AIDS patients and their relatives and relief for women and children after the death of husband or father. The community home care projects established in the urban areas of Copperbelt province in Zambia provide a decent terminal phase for AIDS patients and assist the surviving families in maintaining a certain socioeconomic level of existence.

PIP: In Zambia more than 1.2 million people have been infected with HIV since the beginning of the epidemic in 1983-84, and approximately 300,000 people have developed AIDS since then. Home care for such patients has been organized either through health care institutions (involving visits once every two weeks or a month to the home by medical and nursing personnel) or through the community with outside support, mainly from a nongovernmental organizations (NGOs) such as Memisa. In 1991 a home care program for chronically ill patients was launched by the bishopric of Ndola in the province of Copperbelt. In 5 towns with 400,000-450,000 inhabitants, home care projects were initiated for these patients, who constitute more than 90% of cases of symptomatic HIV infections. Palliative care has evolved over the years toward a holistic form of care consisting of a combination of medical treatment, psychological and pastoral support, counseling and, in some cases, material assistance. The results of the home care are that the quality of the lives of terminal patients have improved, the community has fully accepted the projects, the volunteers and nurses are more alert to the symptoms of serious opportunistic infections, the treatment of tuberculosis has improved, and more openness about AIDS and HIV infection has made possible a positive life concept for many patients. The project also provides support (school fees, clothes, food for children) for the families of patients. Income-generating projects also provide sources of income--mainly for women whose income has been lost as a result of AIDS. In 1996 this project assisted approximately 6000 patients and their families.

Uganda: improving maternal health care efficiency and financing.

PIP: This article presents the findings of the Partnerships for Health Reform on the efficiency and financing issues of maternal health services of the Ugandan Ministry of Health. A comparison was made between provider and consumer maternal health service expenditures provided by a public and a mission hospital and center, and by 17 private midwives and 20 traditional birth attendants (TBAs). The six areas covered by the study include antenatal care, normal deliveries, cesarean deliveries, postabortion care and postpartum hemorrhage and eclampsia complications. Greater health service cost was noted among mission hospitals compared with public hospitals and health centers, while prices for cesarean deliveries and treatment of obstetrical complications are higher compared with other maternal health services. Records show relative efficiency indications of the various providers, while quality of services were noted among midwives working in hospitals and centers compared with TBAs. Most consumer costs were observed to be lower compared with other care-related expenses except for mission health care cost. Thus, mission facilities recover more financially compared with public health centers and hospitals. Key actions suggested include: increasing health service utilization, streamlining staffing, improving the drug supply, employing midwives, assessing prescription practices, establishing specific times for check-ups, regulating consumer fees and provision of contracting arrangements, intensifying performance incentives, and evaluating user incomes and the ability of the public to pay for health care services.^ieng

In Uganda, elders work with the UN to safeguard women's health.

PIP: This article reports on the 1998 UN population award that was given to Uganda's Sabiny Elders Association (SEA) for its work in combatting female circumcision (FC) among the Sabiny people in Eastern Uganda's Kapchorwa district. The elders aimed at documenting local history and preserving the rich cultural heritage of Sabiny society while promoting changes in various cultural traditions that were inconsistent with modern ways of living. They also aimed to promote education especially among girls, to protect the region's environment and wildlife, and to develop its traditional medicine. Helping the victims of HIV/AIDS was a part of their goals. The UN Population Fund (UNFPA) launched its REACH program in Kapchorwa to assist the Sabiny community in bringing about its own social change and to join with them in eliminating FC, in 1996. A more appropriate ritual for ushering a girl into womanhood is being contemplated.^ieng

AIDS: the agony of Africa. Part Three: Africa responds. Bereft of medicine and money, traditional cultures mobilize in a new way.

PIP: Africa's response to AIDS is often depicted to be as dysfunctional as its economy. Only a handful of African governments have mobilized a response remotely commensurate with the magnitude of the epidemic, which has already decreased life expectancy by as much as 20 years in some countries. In Zimbabwe, where a quarter of the people aged 15-49 years are infected with HIV, the response to the AIDS epidemic can be found in extremes. While the government is spending more than 70 times the budget of the AIDS Programme on its military intervention in the Democratic Republic of Congo, individual communities are setting up vigorous responses to AIDS. The Insiza Godlwayo AIDS Council (IGAC) is one such group organized by individual communities and headed by ordinary peasant farmers. IGAC specializes in home-based care and orphan support; it has also launched a youth prevention campaign. It has 500 active volunteers and another 500 who help out as needed. With an annual budget of less than US$17,000, volunteers are asked to pay dues, give food and other necessities directly to their patients. The response of IGAC to AIDS is a reclamation of the age-old ways that enabled African communities to withstand previous scourges. IGAC is successful because villagers have been mobilized and banded together for communal endeavors.^ieng

Using herbs.

PIP: In Tanzania, the Tanga AIDS Working Group (TAWG) encourages traditional healers and biomedical health workers to work together to improve HIV prevention and care. It is active in three regional towns and provides care for over 400 people living with AIDS. Its services include pretest and posttest counseling. It also dispenses traditional medicines and biomedicines for the treatment of opportunistic infections symptoms. TAWG is also involved in researching potentially useful herbal remedies. Moreover, the group conducts seminars with local traditional healers and traditional birth attendants on topics such as basic facts about HIV/AIDS, transmission and prevention, and when and where to refer people to biomedical facilities.^ieng

Promoting collaboration.

PIP: In Uganda, THETA (traditional and modern health practitioners together against AIDS and other diseases), is promoting collaboration between traditional and biomedical health workers in the prevention and care of sexually transmitted infections (STIs) including HIV/AIDS. Its first project involved collaboration in clinical trials to study the effectiveness of herbal treatments for opportunistic infections. The second was to empower traditional medicine practitioners to offer counseling and education on STIs/HIV. This article describes the training curriculum developed in collaboration with The AIDS Support Organization and with the participation of healers and local women, and the strategies in which the healers used the training. Some traditional healers became involved in community education, others in counseling and still others started HIV-support groups. Overall, the community education and counseling increased understanding about HIV and resulted in some behavior change, including an increase in condom use. By respecting their knowledge, experience and beliefs, THETA gained the trust of the traditional healers, and was expanded to cover some 210 traditional healers in seven districts of Uganda.^ieng

Johns Hopkins wins $16 million award to continue integrated health project in Uganda.

PIP: The Johns Hopkins University Center for Communication Programs has won a $16 million award from the US Agency for International Development to continue an integrated health project in Uganda. "Care for Others, Care for Yourself" is the slogan of the new project, which will continue to strengthen and expand the "one-stop" health services. These services enable clients to take care of a majority of their maternal, infant, and reproductive health needs and to get advice about AIDS prevention, nutrition, and breast-feeding. In addition, the new project will increase its coverage on children's health and provide long-term and permanent contraceptive methods, emergency contraception, emergency obstetric care, postabortion care, and adolescent reproductive health. The project was built on the principle of an integrated quality care through a sustainable decentralized program.^ieng